Assessing BPPV in a blind patient

[psychophysio]

Greetings
I am looking for some opinion/advice.

I was asked to assess a man for possible BPPV (Benign Positional paroxysmal vertigo) and treat him as indicated. He is 70, blind since birth (congenital retinal defects or something like that), reported positional dizzyness/vertigo with sit to stand, head turning in either direction, lasted 30 seconds, resolving with rest.
On examination: Dix-Hallpike negative to left and right (no nystagmus, no vertigo) and he had some other neuro signs on exam (left dysmetria, left incoordination, ataxic gait) so I actually think he has had a left cerebellar or brainstem CVA.

My question is: would you expect to see nystagmus in a blind man with BPPV after a Dix-Hallpike manoeuvre? I would have thought yes, since the otoconia would be moving and nystagmus is a response to that, but I was wondering if any of you have any other experiences or opinions.

Cheers,
mike

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[Gawaine]

strictly speaking based on my own opinion, i would expect a blind pt with BPPV to have a positive hallpike... while nystagmus may or may not be present, you should at least have some vertigo... though i've never had the experience of dealing with that...

i'd be curious to see the MRI... does the patient complain about general dizziness or actual vertigo? and were they blind from birth? i wonder if that would make a difference too... would a blind-since-birth person experience vertigo?

good questions.......


patrick

[psychophysio]

He is blind from birth and the MRI came back normal. he is still unsteady on his feet though, so not really sure what has caused that - maybe something vestibular?

I asked a visiting neurologist what to expect about the BPPV and he said you would still get nystagmus etc as the test is one of the vestibulo-ocular reflex (or something like that), not the visual pathways.

As for the "would he experience vertigo" question, I don't know. I would have thought you need some visual input to get the spinning sensation, so maybe not. I had to explain claustrophobia to him when talking about the MRI, which was interesting.

I might see if I can do some vestibular testing on him tomorrow and see what happens....

[Gawaine]

interesting case... i would definitely clear the somatosensory system-- make sure his feet are still sending good signals up... no diabetes or other neuropathy? check the dix-hallpike again-- move him quick and relatively "deep"... i once had a lady who wasn't demonstrating a positive with my student until i took her down just a little faster...
if it's not BPPV but a non-descript vestibular balance disorder, standard balance training removing or decreasing somatosensory input would hopefully help him out... plus increasing the use of his somatosensory system and balance reactions should be good...


again, good luck with it!!

[psychophysio]

Well, it has been an interesting couple of weeks for my man....

He developed progressive left side weakness and sensory changes after last weekend. His hand power was 2/5 (5/5 on admission) & he developed some leg weakness too. He was reviewed by the rehab registrar to come down there and he queried a cervical spine lesion. One urgent MRI later we found a left C4-5 disc bulge with cord oedema.

The neurologist examined him and his impression was:
C4-5 disc bulge with Brown-Sequard pattern of stmptoms
Resolving vestibular neuronitis
Diabetic neuropathy

The patient had decompression surgery last week which was successful (halted progression of symptoms) and he is in rehab at the moment. I will keep an eye on how he does.

Thanks for your input and suggestions Patrick - he really is an interesting patient to assess and treat. In hindsight I wish that I did reflex testing with him as it would have been interesting to see if they were all intact on admission. I mnight dig out his notes and see what the doctors found.